老年人抗高血压药物的停药。

IF 8.8 2区 医学 Q1 MEDICINE, GENERAL & INTERNAL
Danijela Gnjidic, Aili V Langford, Vanessa Jordan, Mouna Sawan, James P Sheppard, Wade Thompson, Adam Todd, Ingrid Hopper, Sarah N Hilmer, Emily Reeve
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引用次数: 0

摘要

背景:高血压是随后心血管事件的重要危险因素,包括缺血性和出血性中风、心肌梗死和心力衰竭,以及慢性肾脏疾病、认知能力下降和过早死亡。总的来说,抗高血压药物的使用导致心血管疾病、发病率和死亡率的降低。然而,抗高血压药物的使用也与危害有关,特别是在老年人中,包括药物不良反应和药物相互作用的发生,并可能导致药物相关负担增加。因此,一些老年人停用抗高血压药物可能被认为是合适的。目的:评价停用降压药对老年人高血压或心血管疾病一级预防的影响。检索方法:在本次更新中,我们检索了截至2022年10月的Cochrane高血压专科登记册、CENTRAL(2022年,第9期)、Ovid MEDLINE、Ovid Embase、WHO ICTRP和ClinicalTrials.gov。我们还进行了参考文献检查和引文检索,并在适当的时候联系研究作者以确定任何其他研究。搜索没有语言限制。选择标准:我们纳入了老年人(定义为50岁及以上)用于高血压或心血管疾病一级预防的降压药物的停药与继续的随机对照试验(RCTs)。符合条件的参与者居住在社区、老年护理机构或医院。我们纳入了评估所有抗高血压药物完全停药的试验,以及那些专注于减少抗高血压药物剂量的试验。数据收集和分析:我们使用连续变量的平均差异(MD)和95%置信区间(95% CI),以及二元变量的Peto优势比(ORs)和95% CI,比较停药或减少抗高血压药物治疗与继续抗高血压药物治疗的干预。我们的主要结局是死亡率、心肌梗死、药物不良反应或药物停药不良反应的发生。次要结局包括住院、中风、血压(收缩压和舒张压)、跌倒、生活质量和成功退出抗高血压药物。两位综述作者独立地、一式两份完成了研究选择、数据提取和质量评估的所有阶段。主要结果:我们在本次更新中没有发现新的研究。原始综述中的6项rct符合纳入标准,纳入本综述(1073名受试者)。研究时间和随访时间从4周到56周不等。研究荟萃分析显示,与继续服用抗高血压药物相比,停止服用抗高血压药物可能导致全因死亡率几乎没有差异(OR 2.08, 95% CI 0.79至5.46;P = 0.14, i2 = 0%;4项研究,630名参与者;证据的低确定性),并且证据对心肌梗死的影响非常不确定(OR 1.86, 95% CI 0.19至17.98;P = 0.59, i2 = 0%;2项研究,447名受试者;证据的确定性非常低)。无法对药物不良反应和戒断反应的发生情况进行meta分析;关于停药对药物不良反应风险的影响,证据非常不确定(证据的确定性非常低),而且纳入的研究没有专门评估药物停药不良反应。一项研究报告了住院情况;停用抗高血压药物可能导致住院率几乎没有差异(OR 0.83, 95% CI 0.33至2.10;P = 0.70;1项研究,385名参与者;证据的低确定性)。荟萃分析显示,停用抗高血压药物可能导致卒中的差异很小或没有差异(OR 1.44, 95% CI 0.25至8.35;P = 0.68, i2 = 6%;3项研究,524名参与者;证据的低确定性)。停药组血压可能高于继续用药组(收缩压:MD 9.75 mmHg, 95% CI 7.33 ~ 12.18;P < 0.001, i2 = 67%;5项研究,767名受试者;证据的低确定性;舒张压:MD 3.5 mmHg, 95% CI 1.82 ~ 5.18;P < 0.001, i2 = 47%;5项研究,768名受试者;证据的低确定性)。没有研究报告有跌倒。偏倚的来源包括选择性报告(报告偏倚),结果评估缺乏盲性(检测偏倚),结果数据不完整(流失偏倚),以及参与者和人员缺乏盲性(表现偏倚)。作者结论:2020年综述的主要结论仍然适用。停用抗高血压药物可能导致死亡率、住院率和中风的差异很小甚至没有差异。 关于停止抗高血压药物对心肌梗死、药物不良反应和药物停药不良反应的影响,证据非常不确定。停用抗高血压药物可能导致血压升高。目前还没有关于对摔倒的影响的信息。证据的确定性低至极低,主要是由于研究规模小,事件发生率低。这些限制意味着我们不能得出任何关于抗高血压药物处方对这些结果的影响的确切结论。未来的研究应集中在获益不确定性最大的人群:使用降压药物的风险比,如体弱者、老年群体和服用多种药物的人群,并测量临床重要的结果,如药物不良事件、跌倒和生活质量。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Withdrawal of antihypertensive drugs in older people.

Background: Hypertension is an important risk factor for subsequent cardiovascular events, including ischaemic and haemorrhagic stroke, myocardial infarction, and heart failure, as well as chronic kidney disease, cognitive decline, and premature death. Overall, the use of antihypertensive medications has led to a reduction in cardiovascular disease, morbidity rates, and mortality rates. However, the use of antihypertensive medications is also associated with harms, especially in older people, including the development of adverse drug reactions and drug-drug interactions, and can contribute to increasing medication-related burden. As such, discontinuation of antihypertensives may be considered appropriate in some older people.

Objectives: To evaluate the effects of withdrawal of antihypertensive medications used for hypertension or primary prevention of cardiovascular disease in older adults.

Search methods: For this update, we searched the Cochrane Hypertension Specialised Register, CENTRAL (2022, Issue 9), Ovid MEDLINE, Ovid Embase, the WHO ICTRP, and ClinicalTrials.gov up to October 2022. We also conducted reference checking and citation searches, and contacted study authors to identify any additional studies when appropriate. There were no language restrictions on the searches.

Selection criteria: We included randomised controlled trials (RCTs) of withdrawal versus continuation of antihypertensive medications used for hypertension or primary prevention of cardiovascular disease in older adults (defined as 50 years of age and over). Eligible participants were living in the community, residential aged care facilities, or based in hospital settings. We included trials evaluating the complete withdrawal of all antihypertensive medication, as well as those focusing on a dose reduction of antihypertensive medication.

Data collection and analysis: We compared the intervention of discontinuing or reducing the dose of antihypertensive medication to continuing antihypertensive medication using mean differences (MD) and 95% confidence intervals (95% CIs) for continuous variables, and Peto odds ratios (ORs) and 95% CI for binary variables. Our primary outcomes were mortality, myocardial infarction, and the development of adverse drug reactions or adverse drug withdrawal reactions. Secondary outcomes included hospitalisation, stroke, blood pressure (systolic and diastolic), falls, quality of life, and success in withdrawing from antihypertensives. Two review authors independently, and in duplicate, conducted all stages of study selection, data extraction, and quality assessment.

Main results: We identified no new studies in this update. Six RCTs from the original review met the inclusion criteria and were included in the review (1073 participants). Study duration and follow-up ranged from 4 weeks to 56 weeks. Meta-analysis of studies showed that discontinuing antihypertensives, compared to continuing, may result in little to no difference in all-cause mortality (OR 2.08, 95% CI 0.79 to 5.46; P = 0.14, I2 = 0%; 4 studies, 630 participants; low certainty of evidence), and that the evidence is very uncertain about the effect on myocardial infarction (OR 1.86, 95% CI 0.19 to 17.98; P = 0.59, I2 = 0%; 2 studies, 447 participants; very low certainty of evidence). Meta-analysis was not possible for the development of adverse drug reactions and withdrawal reactions; the evidence is very uncertain about the effect of antihypertensive discontinuation on the risk of adverse drug reactions (very low certainty of evidence), and the included studies did not assess adverse drug withdrawal reactions specifically. One study reported on hospitalisations; discontinuing antihypertensives may result in little to no difference in hospitalisation (OR 0.83, 95% CI 0.33 to 2.10; P = 0.70; 1 study, 385 participants; low certainty of evidence). Meta-analysis showed that discontinuing antihypertensives may result in little to no difference in stroke (OR 1.44, 95% CI 0.25 to 8.35; P = 0.68, I2 = 6%; 3 studies, 524 participants; low certainty of evidence). Blood pressure may be higher in the discontinuation group than the continuation group (systolic blood pressure: MD 9.75 mmHg, 95% CI 7.33 to 12.18; P < 0.001, I2 = 67%; 5 studies, 767 participants; low certainty of evidence; and diastolic blood pressure: MD 3.5 mmHg, 95% CI 1.82 to 5.18; P < 0.001, I2 = 47%; 5 studies, 768 participants; low certainty of evidence). No studies reported falls. The sources of bias included selective reporting (reporting bias), lack of blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), and lack of blinding of participants and personnel (performance bias).

Authors' conclusions: The main conclusions from the 2020 review still apply. Discontinuing antihypertensives may result in little to no difference in mortality, hospitalisation, and stroke. The evidence is very uncertain about the effect of discontinuing antihypertensives on myocardial infarction and adverse drug reactions and adverse drug withdrawal reactions. Discontinuing antihypertensives may result in an increase in blood pressure. There was no information about the effect on falls. The evidence was of low to very low certainty, mainly due to small studies and low event rates. These limitations mean that we cannot draw any firm conclusions about the effect of deprescribing antihypertensives on these outcomes. Future research should focus on populations with the greatest uncertainty of the benefit:risk ratio for the use of antihypertensive medications, such as those with frailty, older age groups, and those taking polypharmacy, and measure clinically important outcomes such as adverse drug events, falls, and quality of life.

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来源期刊
CiteScore
10.60
自引率
2.40%
发文量
173
审稿时长
1-2 weeks
期刊介绍: The Cochrane Database of Systematic Reviews (CDSR) stands as the premier database for systematic reviews in healthcare. It comprises Cochrane Reviews, along with protocols for these reviews, editorials, and supplements. Owned and operated by Cochrane, a worldwide independent network of healthcare stakeholders, the CDSR (ISSN 1469-493X) encompasses a broad spectrum of health-related topics, including health services.
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